Parent 1 Name, Age & Occupation
Parent 2 Name, Age & Occupation
If adults in the household work outside the home, what child care arrangements are made for this child?
A. Pregnancy & Birth
1. Mother's age at birth
2. Did mother have any illness during pregnancy?
3. Did she take medications other than vitamins & iron?
4. Was the baby on time?
5. What was the birth weight?
6. Did the baby have any trouble starting to breathe?
7. Did the baby have any trouble while in the hospital?
If yes, what kind?
B. Past Medical History
1. Where has your child gone for check-ups until now?
2. Date of last check-up
3. Date of last dental check-up
4. Has your child had allergic reactions to any medications, foods or insect bites?
5. Has your child had any reactions to any immunizations?
6. Any hospitalizations other than for birth?
7. Any serious injuries?
8. Are any medications taken regularly?
C. Family History
1. Are the child's parents both in good health?
Select any diseases that this child's parents, grandparents, brothers, sisters or aunts and uncles have had:
3. List age, sex and general health of brothers and sisters
4. Have any of your children died?
D. Feeding & Nutrition
1. Is your child's appetite usually good?
2. Is it good now?
3. Was there severe colic or any unusual feeding problem during the first 3 months?
4. Do any foods disagree with him/her?
5. For the first 6 months, is he/she (was he/she) breast fed or bottle fed?
6. If still on formula, which one do you use?
7. Does he/she take vitamins?
E. Review of Systems
1. Has your child had frequent ear infections?
2. Any eye problems?
3. Has he/she had any problems with teeth?
4. Does he/she have frequent colds or sore throats?
5. Is there asthma, pneumonia or recurrent cough?
6. Does he/she have a heart murmur or any heart problems?
7. Any problems with urination?
8. Any problems with diarrhea or constipation?
9. Have there been any convulsions or other problems with the nervous system?
10. Any eczema, hives or other skin conditions?
11. Has your child ever been anemic?
12. Please list any other medical problems.
F. Development / Behavior
1. At what age did your child sit alone?
2. At what age did he/she walk alone?
3. Did he/she say any words by the time he/she was 1 1/2 years old?
4. How does this child compare to others his or her age?
5. Does he/she have trouble sleeping?
6. What grade is he/she in?
7. Has he/she had any trouble in school?
8. Does he/she get along with other children?
9. Select any of the following that your child has had:
G. Safety / Environment
1. Your home is a:
2. Do you know the hottest temperature of the water in your pipes?
3. Is there a working smoke alarm on each floor in the home?
4. Does your child always use a car seat or seat belt when riding in car?
5. Are there any smokers in the house?
6. Are there any problems with the condition of your home? (peeling paint, insects, rats or mice)
7. Does your child always wear a helmet when riding his/her bicycle?
Do you have a record of immunizations?